Laparoscopic Sigmoid Colectomy with Natural Orifice Specimen Extraction in Sigmoid Volvulus

Sigmoid volvulus (SV), the twisting of the sigmoid colon around its own base, is a relatively rare colonic obstruction form. Endoscopic detorsion is the first-line management option in uncomplicated patients. However, recurrence risk is as high as 90%, with a risk of mortality up to 35%. Although procedures such as sigmoidopexy, sigmoidomesopexy, sigmoidomesoplasty, extraperitonealization, or percutaneous endoscopic sigmoidopexy may prevent or reduce SV recurrence, laparoscopic sigmoid colectomy with natural orifice specimen extraction appears to be the optimal choice in selected cases.


Introduction
2][13] For this reason, practitioners recommend elective treatment, including various surgical or endoscopic procedures, in some selected patients.[16][17] In this editorial, I discuss elective treatment of SV, particularly laparoscopic sigmoid colectomy (LSC) and natural orifice specimen extraction (NOSE), based on our experience with 1076 SV cases over 57.5 years (from June 1966 to January 2024), which constitutes the most comprehensive single-center SV series worldwide. 2,4,6,9,180][21][22] For this reason, the basic principle in the prevention of recurrence is disfiguring the dolichosigmoid. 2,12,234][25][26][27][28][29][30][31][32][33][34][35][36][37][38] However, sigmoid colectomy, particularly LSC, is the most effective surgical technique in preventing recurrence.[41][42][43][44][45][46] Regarding the decision-making process in the elective treatment of SV, there are two important parameters: health status and age of the patients.In the literature, "good/bad, " "low risk/ high risk, " or "unco mpli cated /comp licat ed" terms are generally used in the evaluation of general health status, while the term "young age/old age" is not standardized in the evaluation of age. 1,5,33,34,39As seen, such an evaluation is far from objectivity.However, the American Society of Anesthesiologists (ASA) status is an objective parameter in the evaluation of health status.Similarly, as an alternative to the age limit, "life expectancy" is a better choice, which varies from country to country and generally decreases in due course.According to this objective rating system, ASA 1-3 patients younger than the life expectancy limit are optimal candidates for elective LSC, while other alternatives, particularly PES, may be applied in cases with ASA >3 or older than the life expectancy limit. 40inical Experience Contrary to its low incidence in some areas, including North America, Western Europe, and Australia, SV is relatively common in Türkiye, particularly in our region, Eastern Anatolia.My colleagues and I treated 1076 SV cases over a 57.5-year period between June 1966 and January 2024.In our series, nonoperative detorsion was used in 795 patients (13 barium enema, 351 rigid endoscopy, 431 flexible endoscopy, the latter of which was used since 1988).The success rate was 83.2%, while the mortality, morbidity, and early recurrence rates were 0.6%, 2.1%, and 5.5%, respectively.Urgent surgery was preferred in 488 cases, with 17.4% mortality, 34.2% morbidity, and 0.6% early recurrence rates.Elective sigmoid colectomy (95 open and 21 laparoscopic, the latter of which was used since 2002) was applied in 116 patients.The mortality and morbidity rates were 0% and 11.2%, respectively, while no recurrence was determined in the 57 cases followed up over a mean 22.7-year follow-up period.

Main Points
• Endoscopic detorsion is the first-line treatment route in uncomplicated patients with sigmoid volvulus (SV).
• However, SV tends to recur in 15%-55% of the patients following endoscopic detorsion, with a high mortality risk up to 35%.

Conclusion
Laparoscopic sigmoid colectomy with NOSE has some nonignorable operative and postoperative advantages apart from some paramount issues.Nevertheless, it seems to be the new surgical trend in the elective treatment of SV.In my opinion, the next step may be the urgent LSC with NOSE following endoscopic or percutaneous decompression of SV.

Table 1 .
Reports on Laparoscopic Sigmoid Colectomy with Natural Orifice Specimen Extraction in Sigmoid Volvulus ASA, American Society of Anesthesiologists score; BMI, body mass index; F, female; M, male; n/a, not applicable; SPD, single port device.V, transvaginal.